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Teaching clinical communication - an amazing effort Yet why do we still feel we haven’t cracked it? Jonathan Silverman

Teaching clinical communication - an amazing effort Yet why do we still feel we haven’t cracked it? Jonathan Silverman Utrecht 2011. Teaching clinical communication - an amazing effort Yet why do we still feel we haven’t cracked it?. Plan.

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Teaching clinical communication - an amazing effort Yet why do we still feel we haven’t cracked it? Jonathan Silverman

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  1. Teaching clinical communication - an amazing effort Yet why do we still feel we haven’t cracked it? Jonathan Silverman Utrecht 2011

  2. Teaching clinical communication - an amazing effort Yet why do we still feel we haven’t cracked it?

  3. Plan • What undermines clinical communication teaching? • The central importance of integration • Why “communication” is the wrong name and “patient-centredness” is even worse • The problems with Calgary-Cambridge

  4. Plan • What undermines clinical communication teaching? • we work in rarefied isolation

  5. Plan • What undermines clinical communication teaching • we work in rarefied isolation • we are surrounded by inappropriate modelling

  6. Plan • What undermines clinical communication teaching • we work in rarefied isolation • we are surrounded by inappropriate modelling • we artificially separate communication from medical content

  7. Plan • What undermines clinical communication teaching • we work in rarefied isolation • we are surrounded by inappropriate modelling • we artificially separate communication from medical content • we haven’t got assessment right • we haven’t worked out how best to use the various teaching disciplines

  8. Do real clinicians model this? Does bedside teaching back it up? Do learners think it is an add-on? Is clinical communication integrated into all clinical challenges that learners learn? Who doesn’t teach it? Is there a planned curriculum? When doesn’t it occur? Is it rigorously assessed and by the correct methods? Do the teachers understand the research? Have teachers been trained?

  9. Learners still often perceive clinical communication teaching as an optional extra, not central to their learning

  10. Plan • What undermines clinical communication teaching • The central importance of integration • Integration with history taking skills • Integration with practical skills • Integration with specialty teaching • Integration with the hidden curriculum

  11. Plan • What undermines clinical communication teaching • The central importance of integration • Integration with history taking skills • Integration with practical skills • Integration with specialty teaching • Integration with the hidden curriculum • The crucial role of assessment in integration

  12. Plan • What undermines clinical communication teaching • The central importance of integration • Integration with history taking skills • Integration with practical skills • Integration with specialty teaching • Integration with the hidden curriculum • The crucial role of assessment in integration

  13. Plan • What undermines clinical communication teaching • The central importance of integration • Integration with history taking skills

  14. Are communication skills and traditional history taking mutually incompatible?

  15. Are communication skills and traditional history taking mutually incompatible? Have you seen this problem?

  16. Communication skills teaching model versus Traditional medical history model

  17. How you communicate Process Open Directive Three elements of gathering clinical information Biomedical Patient’s perspective What you discuss, record and present Content Clinical reasoning Feelings What you think and feel Perception

  18. How you communicate Process Open Three elements of gathering clinical information Patient’s perspective What you discuss, record and present Content Feelings What you think and feel Perception

  19. How you communicate Process Directive Three elements of gathering clinical information Biomedical What you discuss, record and present Content Clinical reasoning What you think and feel Perception

  20. How you communicate Process Open Directive Three elements of gathering clinical information Biomedical Patient’s perspective What you discuss, record and present Content Clinical reasoning Feelings What you think and feel Perception

  21. Communication model (process) • Initiating the session • Gathering information • Building relationship • Structuring the interview • Explanation and planning • Closing the session

  22. Traditional Medical History Model (content) • Chief complaint •  History of the present complaint •  Past medical history •  Family history •  Personal and social history •  Drug and allergy history •  Systematic enquiry

  23. Confusion between process and content: • GP/psychiatry/psychology v real doctors • The issue of how learner’s are observed (if they are) • How to obtain information v. how to present info • How to obtain information v. how to write down info

  24. Another confusion between process and content Communication skills teachers have introduced their own new content

  25. content to be discovered in gathering information: • the bio-medical perspective • (disease) • sequence of events • symptom analysis • relevant systems review • background information - context • past medical history • drug and allergy history • family history • personal and social history • review of systems

  26. content to be discovered in gathering information: • the patient’s perspective • (illness experience) • ideas and beliefs • concerns and feelings • expectations • effects on life

  27. content to be discovered in gathering information: • the bio-medical perspective the patient’s perspective • (disease) (illness) • sequence of events ideas and beliefs • symptom analysis concerns • relevant functional enquiry expectations • effects on life • feelings • background information - context • past medical history • drug and allergy history • family history • personal and social history • review of systems

  28. So what’s the solution?

  29. Effective history taking is essential to the practice of high quality medicine

  30. Effective communication is essential to the practice of high quality medicine

  31. Effective clinical methodis essential to the practice of high quality medicine

  32. THE CALGARY- CAMBRIDGE GUIDESTO THE MEDICAL INTERVIEW Kurtz, Silverman, Benson and Draper (2003) Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides Academic Medicine;78(8):802-809

  33. Initiating the session preparation establishing initial rapport identifying the reasons for the consultation Gathering information Providing structure Building the relationship exploration of the patient’s problems to discover the: biomedical perspective  the patient’s perspective  background information - context making organisation overt attending to flow using appropriate non-verbal behaviour developing rapport involving the patient Physical examination Explanation and planning providing the correct type and amount of information aiding accurate recall and understanding achieving a shared understanding: incorporating the patient’s illness framework planning: shared decision making Closing the session ensuring appropriate point of closure forward planning

  34. Plan • What undermines clinical communication teaching • The central importance of integration • Integration with history taking skills • Integration with practical skills • Integration with specialty teaching • Integration with the hidden curriculum • The crucial role of assessment in integration

  35. The crucial role of assessment in integration Assessment essential for driving the communication curriculum forward Assessment acts a tool for integration: it should place communication appropriately within all clinical challenges

  36. Assessment drives the curriculum motivates learners to learn legitimises the importance of the subject to learners encourages the acceptance of the subject by otherwise sceptical faculty

  37. Communication skills must be included in assessments, even if such skills are more difficult to quantify and assess than lower levels of learning Assessments should be matched to the learning objectives of the communication skills curriculum  The methods of assessment should mirror the methods of instruction and not undermine the teaching

  38. Simulated Clinical Encounter Examination (SCEE)

  39. Description of the SCEE • OSCE-style examination • 10 stations • 4 stations of history taking and clinical reasoning • 3 stations of explanation and planning • 3 stations of other inter-personal skills • Simulated patients and examiners • 2 hours 40 mins face-to-face testing time

  40. What does the SCEE test? • Process skills of doctor-patient communication • Integrated with content and clinical reasoning • Tests clinical competence in the medical interview

  41. Plan • What undermines clinical communication teaching • The central importance of integration • Why “communication” is the wrong name and “patient-centredness” even worse

  42. Plan • What undermines clinical communication teaching • The central importance of integration • Why “communication” is the wrong name and “patient-centredness” even worse • The problems with Calgary-Cambridge

  43. The Calgary-Cambridgeguides: the ‘teenageyears’ THE CLINICAL TEACHER 2007; 4: 87–93 87

  44. Plan • The problems with Calgary-Cambridge • Different clinical contexts • Flexibility

  45. Plan • The problems with Calgary-Cambridge • Different clinical contexts • Flexibility • Reductionist • Checklist • Received wisdom

  46. Conclusion Integrate Collaborate Invest in faculty training

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